Camps -Parties- Programs for Kids !

1. Z A 2 Modeling Camps-Parties-ProgramsforKids! TM Payment Authorization form Name of Student:_________________________________ Name of Class/Party or Program:__________________________________ Type of Credit Card:_______________________________ Visa, MasterCard, Discover, AM EX, Debit Name of Credit Card Holder:______________________________ Primary Phone Number:____________________________Email:_____________________________________________________ Address of Card Holder:_______________________________________________________________________________________ Credit Card Number:________________________________________ Expiration Date:_____________ Three or Four Digit Code:_________ I authorize Modeling A2Z make an initial charge to my credit card for the following amount $______________ I authorize Modeling A2Z make a balance charge to my credit card for the following amount $___________ on __________ Date Signature of Card Holder:________________________________________Date:______________ Email to: registration@modelinga2z.com or Fax to: 1-301-874-8657 2 Tel. (301) 801-4556 MODELING AZ, LLC * P.O. Box 150 * Adamstown, MD 21710 * * Fax (301) 874-8657 www.modelinga2z.com